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Proof that American Physicians and Hospitals Can Lift Quality and Reduce Costs

The media has been paying too much attention to the lies about health care reform that the conservatives have been circulating. Perhaps this is understandable: they are Big Lies, colorful canards, horrifying rumors. But they are simply, totally wrong—made up out of whole cloth.

The job of the media is not to repeat rumors, but to present facts—so that the public can draw rational conclusions from empirical evidence. Today, the New York T.imes ran an Op-ed signed by Drs. Atul Gawande, Donald Berwick Elliott Fisher and Mark McClellan that does just that. http://www.nytimes.com/2009/08/13/opinion/13gawande.html?pagewanted=1&_r=1&hpThe four tell the story of ten U.S. communities that have managed to do what progressives claim health care reform can do: “change how care is delivered so that it is both less expensive and more effective.”We don’t have to ration care. We don’t have to raise taxes for the middle-class or the upper-middle class. We may need modest tax hikes for the very wealthy to seed healthcare reform. But structural changes in our health care system can ultimately provide the savings needed to offer high quality, affordable care to everyone.

On the Lehrer Report, health-care correspondent Betty Anne Bowser visited an integrated multi-specialty clinic in Billings, Montana that has managed to reduce health care spending by improving the quality and safety of care. There, 240 physicians work together, on salary, in a single system. At the center of that system: the patients who enjoys better care for less.

Opponents of health care reform say that this just can’t be done. The claim that if we reduce spending we will be forced to ration needed care. Why are they so negative? They want to see our national health care bill continue to grow because they represent those who profit from runaway health care inflation. Those who speak out against reform are not trying to protect patients—they are trying to protect the interests of our for-profit health care industry.

Meanwhile, the naysayers are denying reality. As the New York Times Op-ed points out, true reform can happen anywhere in America. Here’s the list of the ten communities that have transformed their health care systems and now boast better outcomes for less. : Asheville, N.C.; Cedar Rapids, Iowa; Everett, Wash.; La Crosse, Wis.; Portland, Me.; Richmond, Va.; Sacramento; Sayre, Pa.; Temple, Tex.; and Tallahassee, Fla., There is nothing extraordinary about these cities except for the fact that local health care providers have gotten together, and decided to do something about the waste in their system.

Physicians and hospital leaders in Cedar Rapids began by counting how many CAT scans they were doing, only to find that in just one year 52,000 scans were done in a community of 300,000 people. “I was embarrassed for us,” confides Jim Levett, a cardiac surgeon and the head of a large physician group in Cedar Rapids. It’s just not likely that 1/6 of the population needed a CAT scan in a given year. Moreover, as the Op-ed points out, “A large portion of them were almost certainly unnecessary, not to mention possibly harmful, as CAT scans have about 1,000 times as much radiation exposure as a chest X-ray.”

The stories of how these communities reformed their health care systems vary, but two common themes emerge. First, most moved away from fee-for-service, finding other ways to pay doctors. (Even those that retained some form of fee-for-service blunted the effect by pooling fees.) Secondly, collaboration replaced destructive competition. Rather than engaging in medical arms races—with each hospital in the community buying the same exorbitantly expensive and redundant equipment—hospitals competed to see who could be more efficient, eliminating unneeded hospital beds, along with unnecessary hospitalizations.

The Lehrer Report ends with an interview with Dartmouth’s Dr. Elliot Fisher who observes that reform doesn’t necessarily mean paying most physicians less, but it does mean “paying them differently by rewarding them for reducing the costs of care.”And it turns out that that Billings is one of 10 medical centers nationwide taking part in a Medicare demonstration project that is trying to find out if these integrated systems can manage chronically ill patients more efficiently. The answer: “yes.”Just one sign of success:they have reduced hospitalizations by 40%.

The House Bill for healthcare reform calls for more Medicare demonstration projects, like this one, that would allow Medicare to experiment with how it pays for care, and how care is delivered. Successful Medicarereforms will, in turn, create a blueprint for the public sector insurance plan that the administration plans to roll out in 2013.As HealthBeat has said from the beginning , Medicare reform will pave the way for national healthcare reform. This is one reason why it is essential that we have a public insurance option that is modeled on a reformed version of Medicare.

23 thoughts on “Proof that American Physicians and Hospitals Can Lift Quality and Reduce Costs”

Maggie – This is critically important evidence that we can improve care while reducing cost contemporaneously. Reforms of this type are essential as part of a reform package that extends coverage to more Americans, because more coverage inevitably places more demands on services, including those that are useful, those that are useless, and those that are harmful – the good, the bad, and the ugly. We must strive to figure out which is which, and retain only the good ones.
What remains, however, is still that elephant in the living room that no-one wants to mention. It’s the “R” word, rationing. No-one, of course would ration services per se by fiat (i.e., the services would always be available to those willing to pay out of pocket), but if rationing is intended to mean denial of those services that exist but are unaffordable, we are burdened today by one of the most heavily-rationed healthcare systems in the developed world. Reforms such as those above would dramatically reduce rationing.
But they wouldn’t eliminate it, and that is why it’s important for the public to understand the realities and to confront them as adults rather than as regurgitators of sound bites. In a world of limited resources, not everyone can have everything in every circumstance.
Unfortunately, this reality can’t be dismissed by the fiction that we need “ration” only ineffective interventions, or those that perform less well than others. At times, even the reduced rationing in a reformed system will inevitably deny something useful to someone who might benefit from it.
Recently, JNCI (the Journal of the National Cancer Institute) published some articles on cetuximab, a biologic with some efficacy in metastatic colorectal cancer refractory to other therapies. Patients receiving cetuximab lived longer than those receiving standard treatment (usually by a few months at most, although a subset of patients did slightly better). No-one was cured, but the benefit was real nevertheless. Its cost, however, was about $300,000 per QALY (quality adjusted life year) gained.
It’s fair to say that this type of cost/utility ratio
is unaffordable for society to bear, and therefore condemns patients who can’t afford the benefit to do without. If that decision is made in establishing insurance benefit criteria, it would be tantamount to “killing granny” in the eyes of the ideologues.
Ideologues on the other side can of course deny that any decisions of this sort would ever be necessary, but I see it as far more important to educate the public to understand the context in which these decisions are made. I expect that if this is done in a way that doesn’t patronize intelligent Americans who are open-minded and receptive to rational discourse, the hurdles politicians face in making tough choices will be lowered, even as the shrill voices unreceptive to reason continue their harangues.

A bit off topic from me for this good blog post but…
PLEASE READ MY LIPS!
The Dems need some very simple straightforward messages on health care reform
(Eggheads step aside until we cross this political goal line)
I offer these four up-
-“Insurance companies routinely deny needed care”
-“Medicines in the US are way too expensive”
-“You will not be able to afford your health insurance premium soon”
-“Grandmothers need our deepest love and respect both in life and in death”
Thanks,
Dr.Rick Lippin
Southampton,Pa

I read the Times piece yesterday by 4 thoughtful heavyweights. It remains to be seen if their ideas have legs, or will be soon forgotten. I congratulate them on a strategy that even a school child would endorse. Seek out those who have succeeded where you have failed and learn from them. For example, the Dartmouth data that demonstrates wildly different geographic cost and quality assessments has been out for years. Yet, has it resulted in any tangible benefit or reform? So many promising ideas just seem to wither.

Maggie – You cite the Medicare demonstrations projects, and then state that it is important to have a public option modeled on a reformed version of Medicare.
While I wouldn’t disagree with that principle, I’m uncertain how the latter would come about at an effective level.
Let’s assume we get a government run public insurance option (although non-profit cooperatives seem more likely at this point). An insurance plan can only pay for what exists. If 99 percent of Americans don’t live in a community served by the type of reformed system represented by the demonstration projects, how could the public plan offer it to them? To me, it gets down to the question of how much of the proposed Medicare reform efforts will have “teeth” that ensure they become widespread. If they are just recommendations, or merely “demonstrations”, would that be enough? I don’t know the answer, but I’d like to hear your response.

Maggie,
Interesting, but what I noticed is that most of these markets are in much smaller cities where it seems possible to develop this type of culture of cost savings and adherance to quality. What we have here in Chicago, and many other places is a larger competitive market of basically large health care institutions that are waging a technological war to see who can build the fanciest hospital and have the latest gizmos. We are bombarded with advertising for the latest and greatest cutting edge therapy with the result being ever increasing health care costs. What you have in your examples may not apply to these larger markets unless the rules are changed to discourage such behavior.
The hospital where I practice is a prime example; it has taken on a series of mergers and acqusitions of surrounding hospitals that essentially created a regional monopoly. They used this market power to leverage higher fees from insurers several years back. The price increases they acheived were so great as to attract the attention of the FTC who brought them to court and won with an initial judgement that they should divest of the acquired hospital. This was reversed on appeal though and their mini monopoly still exists. They have had exceptional profits with a CEO that makes well over 1.5 million a year and have gone on a spending spree upgrading and building new facilities. They have acquired physicians practices and expanded their physician group, having placed clinics and MRI faciities hither and yon. They represent the model that you espouse of the integrated physician group with a sophisticated EMR to communicate through, but I seriously doubt that they have lowered the cost of health care in our region. Under the current reimbursement system, if they invaded one of your market examples, they might overwhelm your examples and result in these cost effective institutions reverting to old habits.
So it is not just the type of organization, but who runs it and what their motivation is. Whether physician or CEO, if money is the main motivator, you will get a higher cost system under the current rules of the game. I am not sure how this transformation will take place when you have individuals who act to create these medical empires which are not necesarily cost eficient.
Another example would be the Mass General system which has leveraged its well known name to squeeze higher reimbursements from insurance companies, putting it’s competition at a financial disadantage. The eventual liklihood is that we would expect them to become the dominant, if not the only player, in the Boston market. And then watch the prices go through the ceiling!

fredmoolten,Dr. Rick, Michael,Dennis, Fredmooten (second comment), Keith . . .
Fredmoolten–
I totally agree that “it is important to educate the public to understand the context in which these decisions are made. I expect that if this is done in a way that doesn’t patronize intelligent Americans who are open-minded and receptive to rational discourse, the hurdles politicians face in making tough choices will be lowered, even as the shrill voices unreceptive to reason continue their harangues.”
But I disagree as to whether we need to “ration” effective care.
More than two decades of Dartmouth research shows that 1/3 of our health care dollars are squandered on unncessary, ineffecitve, often unproven and sometimes unwanted and often over-priced tests, treatments, products and hospitalizations.
That is why we don’t need to “ration.” We need to eliminate as much of the ineffective care as we possibly can. But refusing care that provides no benefit for the patient is not “rationing.”
Rather, we are talking about protecting the patient from being exposed to risks (all medical tests and procedures carry some risk) without benefit.
We also don’t need to “ration” end-of-life care. We need to let palliative care specialists give critically ill patients (or families, if the patient cannot respond) information on the benefits and risks of the treatment options before them. (Palliative care specialists also are experts at keeping patients out of pain.)
Palliative care is Not about giving up on patients. It’s about giving them a chance to particpate in deciding which treatments they want to pursue–and for how long.
That’s what the House bill’s proposal for end-of-life counseling was all about. And it was entirely voluntary– no one would be required to be counseled.
Dr. Rick–
I totally agree with your four messages.
But at this point, the public is so completely confused that I think we need to find a way to tell them more– without making them more confused.
I would add: “The For-Profit health care industry puts profits ahead of patients. We must change this.”
And “More care is not necessarilly better care. Too many Americans are exposed to unncessary tets, procedures and hospitalizations. As a result, they are exposted to risks without benefits.”
The last one is the hard one. But at some point, we have to explain to the American public that refusing to cover ineffective care is Not rationing care.
Michael—
For many years, Dartmouth’s Jack Wennberg (who founded the research)
was a “voice in the wilderness.”
The medical establishment did not want to accept the idea that much of what it did provided no benefit for patients. (Jack calls this the “doctrine of manifest efficacy: if we do it, it must be effective.”)
See this story that I have written about Wennberg and the history of the Dartmouth research herehttp://dartmed.dartmouth.edu/winter07/html/braveheart.php
It wasn’t until sometime in the late 1990s that the majority of the medical cognoscenti acknowledged that Wennberg was right.
(Dr. Elliott Fisher helped Wennberg get the word out.)
In this century , you began to see stories in the mainstream press citing the Dartmouth reserach.
But patients still are very reluctant to believe that their doctor may be recommending something that they really don’t need–something that could hurt them rather than help them.
“Maybe someone else’s doctor–but not my doctor.”
In truth, very very few doctors knowingly put patients at risk.
But our doctors have been trained to “be thorough.” and “Do everything possible.”
It’s going to take time for both doctors and patients to begin seeing medicine differently..
But the process has begun. These 10 communities show that.
Let me be clear: I don’t see this revolution happening in Manhattan, LA or Miama anytime soon.
But in many parts of the country, people are beginning to beoome receptive to the message.
This is in part because they are beginning to realized that unless we do something about health care inflation driven by overuse of medical technologies, the vast majority of us won’t be able to afford health care.
Dennis– Thank you.
FredMoolten–The House bill includes a large section on reforming Medicare–adn giving it the latitute to begin changing how it pays for care (moving away from fee-for-service0 and what it pays for (allowing it to lower fees and probably rasie co-pays for treatments that are less effective. IN other words, Medicare will be able to use the comparative effectiveness reserach.)
Meanwhile the administration has made it clear that it backs the idea of letting an Independent Medicare Advisory Coucil–that is shielded from Cognress and lobbyists — make decions about Medicare fees, adjusting fees with an eye to which treatments and tests actually benefit patients.
Keith–
You make a very good point.
I don’t expect that that majority of doctors and hopsitals in cities like
Chicago, LA, NY, Miami, Houston ,Dallas . .. will voluntarily move toward more effective, less expensive care.
In those cities, what Dr. Atul Gawande called “the culture of money” (in his June 1 New Yorker article) is so tied up with healthcare that it will be very hard to separate the two.
And you are right when you say that an “integrated multi-specialty practice” doesn’t necessarily solve the problem.
As you point out: “it is not just the type of organization, but who runs it and what their motivation is. Whether physician or CEO, if money is the main motivator, you will get a higher cost system under the current rules of the game.”
Yes.
That said, I do think that there are many communities that could begin to do what these 10 communities have done.
But at the same time, we need federal legislation that uses a combination of financial carrots and sticks to change the medical culture in many large cities.
This will be difficult, but I believe that, over time, it can be done.

Maggie – Like you and most of us, I’m outraged by the use of the word “rationing” to imply that reform plans would impose unnecessary restrictions on what services or treatments insurance might cover, when in fact, reform would dramatically reduce the extent to which medically effective treatments would be denied coverage.
On the other hand, you are simply wrong, factually, in asserting that reform would eliminate all “rationing” of this type, because it would not, nor could it.
We live in a world of limited resources, and so no matter how generous and equitable we make insurance coverage, some types of coverage will simply be unaffordable even though they offer a medical benefit to patients that is not achievable by some other means.
I cited a specific example in my earlier post – cetuximab – which extends by a few months the lifespan of patients with metastatic colon cancer at such an enormous cost that society could simply not afford to cover it. There is no current substitute for cetuximab, so identifying the best treatment among many has already been done, and won’t turn up any alternative.
For reform opponents to pretend that this type of “rationing” of insurance coverage is a callous step backward is reprehensible. On the other hand, to assert that this type of rationing won’t be necessary is simply to try to wish away an undeniable reality.

Maggie – An apology – not about content but about style. In my most recent comment yesterday, regarding rationing, I made the statement “You are simply wrong.” In many forums, that would be considered unbearably polite and civil compared with the typical ad hominem attack. Here, however, I notice that you have not (to my knowledge) typically called others “wrong”, but simply said that you disagreed with them, and then gave reasons.
I’m still getting accustomed to this level of civility, so forgive me if I’m not completely up to speed.
Fred Moolten

fredmoolten–
We spend $2.6 trillion on healthcare. One-third of that money is wasted.
Even if we elminated just two-thirds of the waste, we still would have plenty of money to cover all effective treatments for everyone.
There is so much waste in this country –and such unequal distribution of resources–then when it comes to things that cost $$$ we are a long way from limited resources. We just need to redistribute those dollars.
I understand what you are saying about cetuximab, but I don’t consider something that extends my life by a few months (and poor quality months at that if I have colon cancer) to be an “effective treatment.”
I actually see no point in manufacturing drugs that have such limited efficacy, and I would like to see the government make it clear to drug companies that there is no point in spending money trying to develop and market drugs like these–they won’t be included in the Medicare formulary–and if that’s the case, most private insurers would probably follow Medicare’s lead (as they do now) and refuse to cover such drugs.
The only reason that a drug like cetuximab exists is that someone can make money on it by preying on someone else’s irrational fear of death. (Or a doctor’s irrational refusal to accept the fact that his patient is dying; rather than talking to the patient about death, he prsecribes another drug–prolonging the process of dying in a way that is often cruel.
But to my mind saying “no” to a drug like this one is not rationing an effective treatment, it’s just refusing to try to fulfill totally irrational desires.
Finally, I think it’s important to make it clear to the public that we don’t need to ration effective care. Otheweise, some people will insist that we can’t afford the most expensive truly effective care for everyone. (For example, organ transplants for patients are are reasonably good candidates and likely to survive.)-Some people would be inclined to say that such treatments shouldn’t be included in the comprehensive insurance that we guarantee for everyone. They might say that the very rich should be able to buy extra insurance that includes transplants if they wish, but transplants shouldn’t be considered part of “basic” coverage.
,
I diagree. I’m very wary of anything that would lead to two-tier medicine, rationed by ability to pay. I think the same “effective” treatments should be available for everyone. At the same time, I’d rather not see products like cetuximab on the market–a waste of money while creating false hopes.

Hi Maggie – I don’t want to belabor the point about cetuximab, because to some extent, we are disagreeing about semantics. You claim it is “not effective care” and I would say “it is not cost effective care”. Knowing something about cancer patients, I believe that many, after being informed accurately what cetuximab would offer in terms of future months of life, (and also in terms of QALY – quality-adjusted life years) would choose to receive it, so for them it would be effective, even though society can’t afford to cover it. From a political perspective, we probably shouldn’t find ourselves in a situation in which we seem to be telling those patients, “You don’t count.”
In any case, we agree that there would be few interventions capable of making a huge difference rather than a small one, that would need to be denied coverage in a reformed system.
I do disagree with you about why cetuximab was developed. It targets the epidermal growth factor receptor (EGFR), which is an important driving force for malignant cell growth, and an area of much current cancer research. Although cetuximab does not appear to achieve more than modest results, its mechanism of action is analogous to that of Herceptin, a breast cancer treatment that targets a related receptor, and which has been highly effective in an important subset of breast cancer patients. Given the fact that the cetuximab rationale is quite plausible, one can’t really know until human trials are undertaken, how much of its promise would be fulfilled.
Fred Moolten

Fred—
I don’t think universal coverage is about giving patients what they think they want (based on what their brother-in-law got, their fear of death, or TV ads) –it’s about what medical evidence shows would provide a significant benefit–whatever the cost.
I recognize that we, as a society, cannot afford multi-million dollar drugs, but I think that the answer is not “cost-effectivenss rationing”, but rather sending hte signal to Pharma that those unaffordable drugs will never make it to market in this country .
Finally, I worded it poorly when I said the drug shouldnt’ have been developed. I understand why reseraching a drug that gives patients 3 months may be part of the process of finding a different way to fight cancer that might , in turn, lead to a drug that gives patients years of remission.
But I think that work should be done by the NIH.
I don’t think such drugs should go to market. (Though it could be very useful for them to be in blind, randomized clinical trials.)
But once Pharma gets hold of these, it’s goal is to package and market.
The basic reserach should be done in academia and at the NIH–with no licensing to for-profit drug-makers. In other words, we need to roll back Bayh-Dole.

Maggie wrote:
The basic research should be done in academia and at the NIH–with no licensing to for-profit drug-makers. In other words, we need to roll back Bayh-Dole.
———-
Maggie, your reply here is an important one and touches on an area with potential great consequences for the healthcare system. I have talked with many a bright conservative who feels that drug innovations will suffer if we put lids on the market approach to healthcare. However, I believe much of what we have seen in the recent past is great waste spurred on by pharmaceutical company greed and a caveat emptor healthcare system. Therefore in the short run in order to make healthcare more affordable and universal, ideas about making available only proven effective products may allow universal access to such products for a while, but what about longer term. What if truly effective but extremely expensive drugs could be made for individuals and their conditions. We would never by able to afford such things on a universal basis. What would the system do?
I suggest that if NIH or some other socially responsive mechanism controlled all new developments, it would still boil down to allowing individuals to pay for expensive but effective treatments only if they could afford them with their own money, or to limited what gets allowed to be developed to avoid the predicament in the first place?

It seems an important of healthcare reform from Maggie’s perspective is the reorganization of physician groups from single specialty, profit oriented, fee for service organizations to multi-specialty, “pay for performance”, salaried organization like the Mayo Clinic, etc. I think there is some merit to her proposal, but I think that the cultural barriers to this kind of change may be larger than what she thinks.
In the first place, most physicians are part of single specialty groups. Single specialty groups can be difficult enough to manage, but throwing in the more widely conflicting interests of different specialties will make it more difficult. For example in a single specialty group all members would at least be subject to the same fee schedules and have the opportunity to earn the same. In a multi-specialty group salary differences between pediatricians and surgeons (for example) can be large and a source of contention.
I participated in a merger of 6 Radiology Groups that occurred in the mid 90’s. Typically, Radiology groups are “Socialist” fee for service organizations – although the groups are paid based on the procedures they perform, the proceeds are split evenly among the members rather based on productivity. (Many other medical groups are capitalist – they pay their members based on the member’s productivity)
We confronted many difficult issues in this transformation – even though the transformation was much less radical than the kind of transformation that Maggie wishes to see. Some of the groups were happy with a modest work load and a modest salary, other groups wanted to work harder and earn more. Some groups were predominantly generalist, others were highly subspecialized, etc. It took years to develop a (semi) cohesive new group.
Along with the challenges in organization came some substantial benefits. We were able to start our own Teleradiology program, we developed great depth and expertise in mammography, nuclear medicine, etc. To obtain the same “economies of scale” with respect to these types of Radiology programs, we would need to be incorporated into a multi-specialty group many times larger than our 80 member Radiology group – probably at least 1,000 docs.
Obviously, multi-specialty groups do exist and can function well. I would like to point out that the cultural differences that will need to be overcome are not small.

Legacy–
In this case, I would say that persuading phsyciains to work together is not just important “from my persepctive.”
We have a large amount of evidence that outcomes are better when this happens.
At the same time, I agree that many doctors will resist. The resistance will be greatest in large cities like Manhattan where so much of medicine is money-driven.
But there are many places (including these 10 communities) where doctors are more open to the idea that medicine is a team sport, and that it would be much easier–not to mention better for patients–if they worked together, and worried less about how much the other guy is making.
In NYC almost everyone is looking into everyone else’s pocket, but that really isn’t as true in some other parts of the country
Finally, all of this goes back to medical training. We have to educate medical students to work in teams, to be far less competitive and far more collaborative.
To some degree, this means changing the types of students that we admit.
There has already been some change in the culture with the admission of more women. (Some–not all–women tend to be more collaborative, less competitive. And women are likely to value sane working hours over money–especially, of course, if they have chldren. this means like are more likely to be happy to work on salary in a multi-specialty organization.
Many younger doctors also are more comfortable with these organizations. They see how hard it is to run a small practice–give the cost of rents, labor, malpractice insurance, etc., they have no desire to run a small businesss. They would rather be on salary, see patients and let someone else worry about keeping the lights on.
So, with time, the culture will evolve. I hate to sey it, but we just have to wait for some of the older docs with different values to retire. .
NG– I think we need to have someone thinking about what will be good for society as a whole when setting priorities for reserach.
For instance, Alzheimer’s is going to become a huge problem. More and more of us are living long enough to outlive our minds.
The suffering– not just for hte patient, but for the family–is horrible.
And it could happen to any of us.
This is a reason to make reserach into Alzheimer’s a high priority.
By contast, reserach into a drug that will give a cancer patient another few months may, down the road lead to a drug that would change how we attack a particular cancer, and lead to giving patients many more years.
That is a good reason for NIH to do that research.
But I don’t see much value in putting that very expensive drug that gives people a few months on the market–which is what Pharma would do.
I think that research shoudl be done, quietly, by scientists, that they should discuss it among themsleves, share infomraton, adn see where it leads. But don’t try to sell it.
And don’t put the big bucks into research that might extend life by a matter of months.
In general, I would say that when setting priorities, we shoudl focus on medications that will improve the quality of life–rather than extending the number of years that we live.
There is way too much emphaiss on living to 90– or 106. Pushing the envelope in that way is asking for trouble: First
the whole problem of bodies outliving minds.
Then there is the depression and isolation that often accompanies old, old age.
Americans are so afraid of dying. But there are worse things than dying . . .
What would be best, for all of us, is if more of us were able to lead high-quality lives to 80, 83, 85. . . pick a number.
I really think medicine should focus on that goal.
As for the very wealthy buying something that is very expensive and the rest of us can’t afford:
If only a few people can afford it, it just won’t be worth it to drug-makers to package it and market it. The market would be too small.
Fred– I do like the level of civility on this blog-and have cut back on commenting on other blogs where I am a contributor because the comments are so hostile. People don’t want to learn and exchange ideas; they just want to attack.
But your comment didn’t bother me. I do sometimes say “That just isn’t true–” particularly when it’s a myth that has been circulating, and can do real damage.
On rationing and cost-effective, I agree we come to the same practical conclusion. I just think that it is important that we try to educate the public that a “life-saving” drug that gives you three months really isn’t saving your life. And the benefit is pretty small– maybe even non-existent if you are going to be very sick during those months.
There’s just too much emphasis on staving off death, and not enough empahsis on quality of life.
My favorite oncologist tells patients suffering from a cancer that he knows he can’t cure: “I can’t make you well. What you need to think about, is what you want to do with the fore-shortened life that you have left. Do you want to spend it here, in my office, with me and my assistants–undergoing treatments (which might give you extara weeks or even months) or is there something else you would like to do with that time.
Many decide there is something else they would like to do: travel; spend time with family; see old fiends they haven’t seen for a long time . . .
I think the way this doctor talks to them–making it clear that he is always willing to see them–to do further treatments, if that’s what they want–or just to visit–makes all the difference. He isn’t abandoning them, or losing interest in them. But he is being candid: you are dying, and we can’t do anything to stop that.

Well, reform the academics first before betting on their “good intentions.” Many of the academics I know (and I know a LOT) are very envious of the $$ their clinical counterparts have made. So many now feel ‘entitled’ to feed off of a hog trough to fix the wrongs that have been done to them when the ‘smart scientists’ were paid much less than the ‘dumb doctors.’
I have seen this first hand and frequently.
In the past few years the escalation of “senior scientist” salaries has been used as a point to young researchers by the academic machinery.
Again, this is first hand observation.

Apropos of Maggie’s discussion of oncology….
Recently my wife told me that one of her friend’s brothers in law was diagnosed with Stage IV gastric carcinoma – basically a death sentence. We attempted to “hook them up” with one of my partner’s wives (a physician), who acts as an “end of life consultant” – helping people to understand what aggressive chemo/radiation will and more importantly WON’T do for them.
Their situation reminded me of my father in laws “battle” with and death from pancreatic carcinoma. In my father in laws case, he was not well served by the “oncology/industrial complex” and probably ended up with a reduced number of good quality days of life due to his chemo/radiation therapy.
He was diagnosed at age 83 with pancreatic carcinoma – basically a death sentence. He had been a healthy and active 83 year old, who had recently helped renovate housing for the poor under the auspices of his church. I arranged for him to be seen at a local university that is well known for treatment of pancreatic carcinoma. They operated (a “Whipple”) on him and he did fairly well post op – although obviously major surgery like a Whipple is not easy for an 83 year old. After that, the surgeon handed him off to the oncologists, who signed him up for a trial of chemo/radiation. In retrospect, this was a mistake.
I realize that I could be criticized for not doing more to change the course of events myself, but since; I am not an oncologist, I was not his “blood relative”, he was a politically conservative and religious man and his family was medically naïve, my options were limited.
To make a long story short he suffered multiple complications from his chemo/radiation including cardiac arrhythmias with pacer placement, a fall resulting in hip fracture/replacement, multiple episodes of small bowel obstruction, nausea, major debilitation and hair loss (actually no big deal for an 83 year old man). If he gained any extra life span, it was eaten up in the hospital with an NG tube in his nose or at home “sick as a dog”.
I have no quarrel with oncologists per se. They are generally hard working, dedicated physicians facing a very difficult problem. And progress is frequently made in slow incremental steps rather than by huge breakthroughs. Still, I think the oncologists treating my father in law had a conflict of interest between signing up people for their experimental trials vs. stopping and sitting down with someone who has a fatal illness and talking to them about what is best for their personal situation.
And of course from the perspective of our nation’s attempt to provide health care to all, spending our money (he was on Medicare) to increase the life span of an 83 year old by 2 months (spent vomiting) is not a wise choice.
I am not sure that I want to be a foot soldier in the war against cancer – perhaps I am more suited to be a “draft dodger”. If I am ever diagnosed with pancreatic cancer or advanced gastric cancer, I want:
1) A big party where I can say goodbye to my wife, friends, relatives and especially my (soon to be I hope) grandchildren. It will have an open bar and (if I can persuade my wife) strippers jumping out of cakes.
2) Good hospice care available with a clean bed, a cute and friendly nurse and unlimited morphine
3) The money that would have been spent on my futile chemo/radiation spent to send my grandchildren to college (or some other worthy cause).
I realize that this is an anecdote and by itself doesn’t prove anything. But having practiced medicine for more than 25 years, I have seen quite a few of this type of case “up close and personal”. We, as a nation, seem to be suffering from a combination of a lack of common sense and a lack of willpower to make difficult but necessary decisions.

Legacy Flyer –
Your stories make a very good point: American medicine has a very hard time shifting from the pedal to the metal mode that it usually works in to dealing with people who it cannot help. Your father in law was not just poorly served by his oncologists, but also, IMO, his surgeon. A Whipple procedure is useless in most cases of pancreatic cancer and just serves to make the patient’s limited survival time more unpleasant.
Unfortunately, politicians and commentators who seek to block health care reform no matter who or how many people suffer for it have cost us the opportunity to institutionalize the type of consultation you are endorsing, and have deprived many people of a better and more humane death, or at least the opportunity to have the information they need to decide what sort of death they prefer.

Most of the comments I have read center on the changes that must occur among physicians, drug companies, and insurance companies to attain meaningful health care reform. And I agree that these groups need to change (or be changed). But a very important part of the equation also rests with consumers of health care. Patients must accept some of the responsibility for their health. I do not know whether the following statistic was accurate, but when I was a medical student in the 1980s I remember hearing from my attending that about 70% of all hospital admissions were in some way related to the effects of cigarette smoke, alcohol use, and a sedentary lifestyle. To be sure, as physicians we must continue to teach and promote healthy habits, but patients need to share in this responsibility not only for themselves, but also as members of a society that collectively pays for the healthcare of others. As an example, we all know that many risk factors of heart disease are not changeable. But a few are. And as the epidemic of obesity continues to grow so will the number one killer of adults in the U.S. This will continue to add an enormous financial burden for all of us. So, I believe that part of the answer to our health care crisis must take this into consideration. I do not have the answer, but I think physicians are only part of the solution to the obesity problem. Perhaps ancillary healthcare providers and other educators, such as nutritionists, fitness trainers, teachers, etc. can play a more active role in health care reform. Maybe it does “take a village.” Maggie, do you know if this side of the equation is being addressed in Congressional discussions?
Jeff Schrager

Jeff–
Thank you for your comment.
You are absolutely right that a huge share of the
nation’s heatlcare problems are caused by smoking and obesity–not to mention alcoholism and use of illegal drugs.
But here’s the difficult part of this: most of these problems are directly connected to poverty.
Many people believe that if the poor just showed some self-discipline, they could beat these problems.
But medical evidence reveals that the unheatlhy behaviors that lead to premature disease and death are all tied up with the anxiety and depression that accompanies being poor.
If you’re poor, you don’t have much contol over you life. You worry about getting a job or losing a job; you worry about your children–whether they are safe on the street (you can’t afford childcare, adn you have to work for many hours afer they finish school) Bottom-line: you have no control
over your future.
It’s not surprising that the majority of poor people suffer from severe anxiety or depression.
So, they self-medicate– drinking, smoking, taking drugs. They have relatively little hope for the future, so when enaging in self-destructive behavior, they don’t feel that they are risking great opportunities that lie ahead.
Medical reserach now shows that the vast majority of adults who smoke are poor–and suffer from one or more mental diseases.
The solution is not so much “teaching” the poor what to do (fitness trainers, nutritionists) though certain children need gyms and gym classes in public schools (something you have in the suburbs, but not in the ghetto–taxpayers are not willing to support inner city schools) as well as nutritious school lunches (again, somehting you have in affluent areas but not in our sadly neglected public schools in poor rural areas and inner citites.)
Poor adults don’t have a lot of time too spend with fitness trainers and nutritious counselors. They do need smoking cessaton clinics that are free–and that give out free nicotine patches (we know this works)
We haven’t found any counseling programs or medication that help the obese take weight off and keep it off. Even when in doctor-supervised programs, compliant patients put the weight back on. (This hs to do with neruologyo and body chemistry that we are just beginning to understand.)
This administation is putting more money into public schools and community clincs — and this should help.
But to truly address the health problems associated with poverty, we have to launch a new war on poverty.
Johnson’s war reduced levels of poverty but now they are back up–particularly among childrne.
We tolerate far higher levels of poverty than any other developed country, and this goes a long way toward explaining why our poulation is less healthy–even when you compare white Americans to whites in other countries.
(We often think poverty is largely confined to minorities, but this just isn’t true.)
I’ve written about all of this here http://www.healthbeatblog.org/2008/05/whatever-happen.html
And see Dr. Steve Schroeder’s outstanding Shattuck lecture herehttp://content.nejm.org/cgi/content/full/357/12/1221#T1

Jeff Schrager –
“Everyone dies, and that’s a fact.” — Bruce Springsteen.
I am not quite sure what the point you are making is, but if you are suggesting that improving health habits would help solve the problems of the US health care system, that is not correct. Unfortunately, healthy lifestyles do not have a positive effect on the costs of medical care.
While people with poor health habits do absorb more health care cost when they are young, the fact that they die at a younger age ends their costs to the system earlier. People with good health habits go on to survive to an older age, to suffer various health problems related to aging, then in the end to undergo health collapse and the expenses of extended terminal illness and death.
The cost of cataract surgery, joint surgery, prostate surgery, age related cancers, dementias, and so on, added to costs of management of coronary disease, congestive failure, stroke, and other conditions which people with healthy habits suffer from later in life in the end cost more overall than the money spent on people with poor habits.
This is not to say that people should not have good habits. They should, for their own sake. But good health habits will not solve the financial problems of health care, a fact documented by well conducted longitudinal studies. American private insurers would benefit from people having better health habits, since they stop most coverage at 65, but the entire health system and Medicare especially incurs greater costs due to good habits.
Another point: death from heart disease is actually declining in the US, despite the increase in obesity. No one can say why this is for sure, but my guess is that better health care is a factor, especially better anti-hypertensive management and perhaps anti-lipid management and diabetes management. Lower rates of smoking are probably an important factor as well.
Finally, proponents of the role of obesity in the poor performance of US health care by world standards ignore the fact that we have been passed in rates of obesity by several other countries, including Finland, Germany, the Czech Republic, Greece, and several Eastern European countries. Interestingly, they retain their statistical edge in health care results over the US. Obesity is a worldwide problem, with many other countries gaining fast, as it were. There is a new blizzard of data linking obesity to economic prosperity in general and low food prices, especially for processed foods, in particular. Public health specialists from Britain to Japan and everywhere in between are alarmed as the phenomenon of “eatertainment” spreads along with fast food, fatty snacks, and sugary drinks.
In fact, as other countries become more obese, US health profiles actually are becoming better by world standards, since although we remain high in obesity statistics, we are much lower in smoking and alcoholism.
The fault, I am afraid, is in our health care system, not our citizens. Improved access to care and improved concentration on effective low-tech care rather than on less effective high tech care are the most important steps. Improving health habits is a good idea, but we must accept that that will lead to higher, not lower, overall costs.

So:
1. Ten communities have reformed their own regional systems through private-sector means, which is proof that we need more government involvement.
2. “Rationing” is a lie, used by evil conservatives, all of whom only want to protect insurance company profits. We’re only going to deny treatments that are not “effective”. And we’ll let you know what is on that list. As an indicator and example, though, adding 3 more months of your life is not cost-effective if it costs over….?. But don’t call this “rationing” or use the term “death panel”. People will think we’re deciding when they are going to live or die.
3. All who oppose health reform — the “conservatives” — have evil motives, “they” are not arguing in good faith, nor are “they” simply wrong (see above). “They” only use words like “liberty” and “freedom” in public, as the basis for their objections, but “they” don’t really believe them. “Their” goal is really to protect the profits of the insurance companies.
4. What we really need is more “rational discourse.”
Got it.